Provider Demographics
NPI:1073640413
Name:CARLSON, MATTHEW THOMAS (DPT, OCS, COMT)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:THOMAS
Last Name:CARLSON
Suffix:
Gender:M
Credentials:DPT, OCS, COMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3055 ROSLYN ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80238-3323
Mailing Address - Country:US
Mailing Address - Phone:720-848-0000
Mailing Address - Fax:
Practice Address - Street 1:9826 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-3200
Practice Address - Country:US
Practice Address - Phone:708-952-8220
Practice Address - Fax:708-423-5281
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL70012540225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146667Medicare ID - Type Unspecified